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Medicaid May Be Extended to Early Treatment of AIDS

Clinton Administration officials say they will soon propose expanding Medicaid to cover low-income people who have been infected with the virus that causes AIDS but do not show any symptoms of the disease.

The Government could then pay for potent, costly drugs that block development of AIDS.

Researchers recommend use of such drugs, including protease inhibitors, soon after a person has been infected with H.I.V., which causes AIDS. In clinical trials reported over the last 18 months, the drugs have proved surprisingly effective in halting the progress of the disease.

Under current Federal rules, if patients develop AIDS and become disabled, they can qualify for Medicaid. The new drugs often prevent disability, but patients are typically unable to obtain them until they become severely ill.

White House officials and Federal health officials said they would not ask Congress to change the Medicaid law, but would expand coverage by using authority they already have to conduct and approve state demonstration projects.

A summary of the initiative, written by the Department of Health and Human Services, says it will ''assess whether eligibility for Medicaid in the earlier stages of H.I.V. infection is effective in reducing Medicaid costs of care.''

The new drugs can be expensive, costing $8,000 to $16,000 a year. But Federal officials said the drugs could save the Government money by reducing the need for hospital care and by reducing the spread of the virus.

Vice President Al Gore, who requested the studies that led to the new proposal, said: ''Our view is that getting these drugs to people earlier won't cost more in the long run. It may even save money. It will certainly save lives.''

In New York City and in the United States as a whole, the number of deaths from AIDS dropped last year for the first time since the epidemic began in 1981. Officials cited the new drug therapies as a major reason.

Doctors say that protease inhibitors lower the amount of H.I.V. in a person's blood, reducing the likelihood that the person will transmit the virus to others.

Victor F. Zonana, a spokesman for the Department of Health and Human Services, said: ''We believe that a person who's being treated is less infectious, and therefore less likely to transmit the virus, than a person who is not being treated. So there is a strong public health rationale for conducting this demonstration, as well as the obvious humanitarian reasons.''

In April, Mr. Gore asked the department to assess the feasibility of using demonstration projects to provide earlier Medicaid coverage for people with H.I.V. Federal health officials said they had concluded that such projects were feasible. They are now working out details with the Office of Management and Budget and advocates for people with AIDS, including the AIDS Action Council, which suggested the idea.

Francis T. Finnegan Jr., the Medicaid director in Maine, said his state was keenly interested in the idea and had already submitted a preliminary proposal to the Federal Government.

''The introduction of protease inhibitors has radically changed the situation and makes the existing policy seem contradictory,'' Mr. Finnegan said. ''Instead of requiring people to get sick enough to qualify for Medicaid, why not design a program where they can live in society and maintain their jobs but receive assistance for drugs that have this remarkable ability to suppress H.I.V.?''

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Republicans in Congress are generally unaware of the plan and have not criticized it. ''Intuitively,'' said a Republican aide, ''the idea makes sense, but it may be difficult to persuade the Congressional Budget Office that it saves money.''

About half of the 217,000 Americans with AIDS will be on Medicaid at some time, but many low-income people with H.I.V. have been denied coverage because they are not sick enough to meet the disability test. Federal officials said that some patients had lost Medicaid after their condition improved as a result of drug therapy but that these patients needed to continue taking the drugs to keep the virus suppressed.

The Social Security Administration uses a strict definition of disability in deciding whether a person is entitled to disability benefits, which usually lead to Medicaid coverage as well. To meet the test, a person must be ''unable to engage in any substantial gainful activity.''

Timothy M. Westmoreland, a lawyer at the Georgetown University Law Center, said: ''Many people with asymptomatic H.I.V. infection are not eligible for Medicaid. As a result, low-income people with H.I.V. often have no access to medical services that could prevent the onset of illness and the decline of the immune system itself.''

Under section 1115 of the Social Security Act, Federal officials have approved all sorts of experimental state programs that broaden Medicaid eligibility or require greater use of managed care. The Federal Government typically requires states to show that such experiments will not increase Medicaid spending over a five-year period.

Administration officials said they believed that such a showing could be made for the early use of protease inhibitors, though they acknowledged that it might take more than five years to see financial benefits.

''This approach could be cost effective, looking at subsequent years of life saved and improvements in the quality of life,'' says the proposal developed by the Department of Health and Human Services.

The Federal Government and the states are expected to spend $173 billion on Medicaid this year, and researchers estimate that 2 percent of that will go for treatment of AIDS.

Federal officials said they would encourage states to submit proposals for expanded coverage and would help them prepare applications. There will be no limit on the number of demonstration projects, they said.

Since December 1995, the Food and Drug Administration has approved four protease inhibitors: Invirase, made by Roche Laboratories; Crixivan, by Merck and Company; Norvir, by Abbott Laboratories, and Viracept, by Agouron Pharmaceuticals.

H.I.V. destroys or disables certain white blood cells known as T cells, which orchestrate the body's immune response. Mr. Gore said: ''People with H.I.V. must wait until their T cells reach extremely low levels or they develop opportunistic infections, resulting in a diagnosis of full-blown AIDS, before they're eligible for Medicaid. That makes some of the new drugs prohibitively expensive for people who need them. We think this should change.''